Drug-free Interventions to Reduce Pain or Opioid Consumption - - PowerPoint PPT Presentation

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Drug-free Interventions to Reduce Pain or Opioid Consumption Following Total Knee Arthroplasty. A Meta-Analysis.

Dario Tedesco, MD, PhD candidate Postdoctoral Research Fellow Stanford University, Department of Medicine Center for Biomedical Informatics Research

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Disclosures

This project was supported by grant number R01HS024096 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The contents of this work do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. This research was also partially supported by the University of Bologna, Italy. No conflicts of interest to declare.

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Outline

• Background: Total Knee Arthroplasty (TKA) and non-

pharmacological therapies

• Study and methods
• Quality of evidence and main findings
• Conclusions
• Policy Impact

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Background

• TKA is one of the most performed surgeries in the U.S. with

about 675,000 procedures/year and $13B total annual cost.

• First line of treatment is pharmaceutical (local anesthetics,

systemic opioids and NSAIDs). However, many non-drug interventions are used for TKA pain management.

• Conventional postoperative physical therapy is considered the

gold standard for functional recovery and pain management.

Steiner et al., 2012; Cram et al., 2012.

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Background

• The current opioid epidemic termed the “worst drug crisis” in
• America. Opioid overdoses are leading cause of accidental

death, with about 33,000 deaths in 2015.

• Surgery is seen as gateway to opioid addiction.
• Chronic use of opioids is associated with higher risk of

postoperative morbidity and mortality after TKA.

Rudd RA et al., 2016; Zywiel et al., 2011; Waljee et al., 2017; Abbasi 2016.

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Study and methods

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Aim of the study

Which of the most common drug-free interventions for TKA postoperative pain management are effective?

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Study selection

Data sources: Medline, Embase, Cochrane Database of Systematic Reviews, Web of Science, Physiotherapy Evidence, and ClinicalTrials.gov, reference lists hand- searching.

• 5,509 abstracts screened
• 120 abstracts considered appropriate for assessment
• Data extracted from 39 RCTs for meta-analysis
• Included studies published between 1991 and 2015
• Only studies published in English

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Interventions

Five most common non-pharmacological interventions for postoperative pain following TKA in scientific literature:

• Acupuncture
• Continuous Passive Motion
• Cryotherapy
• Electrotherapy
• Preoperative exercise

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Outcomes

Measurements of effectiveness:

• Pain relief
• Visual Analogue Score (VAS) Score
• WOMAC Score
• Opioid consumption
• Morphine equivalents (mg/Kg/48h)
• Time to first Patient Controlled Analgesia (PCA) (minutes)

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Quality of evidence and main findings

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Quality of evidence: the GRADE tool

GRADE is the Cochrane collaboration’s recommended approach for grading the quality of evidence through 5 criteria:

• Risk of bias
• Inconsistency
• Indirectness
• Imprecision
• Publication bias

Guyatt et al, 2011.

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Outcome Intervention Risk of bias Inconsistency Indirectness Imprecision Publication bias GRADE Opioid consumption CPM Serious Serious Not Serious Serious Not Serious ⊕ Very Low Cryotherapy Serious Serious Not Serious Not Serious Serious ⊕ Very Low Electrotherapy Serious Not Serious Not Serious Not Serious Not Serious ⊕⊕⊕ Moderate Acupuncture Serious Serious Not Serious Not Serious Not Serious ⊕⊕ Low NSAID consumption Cryotherapy Very Serious Serious Not Serious Serious Not Serious ⊕ Very Low Time to first PCA Acupuncture Serious Not Serious Not Serious Not Serious Not Serious ⊕⊕⊕ Moderate

Quality of evidence

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Quality of evidence

Outcome Intervention Risk of bias Inconsistency Indirectness Imprecision Publication bias GRADE Pain relief – VAS CPM Very Serious Not Serious Not Serious Serious Not Serious ⊕ Very Low Cryotherapy Very Serious Serious Not Serious Not Serious Serious ⊕ Very Low Electrotherapy Very Serious Serious Not Serious Not Serious Serious ⊕ Very Low Acupuncture Serious Serious Not Serious Not Serious Not Serious ⊕⊕ Low Pain relief – WOMAC CPM Very Serious Not Serious Not Serious Not Serious Not Serious ⊕⊕ Low Preoperative exercise Serious Serious Not Serious Not Serious Not Serious ⊕⊕ Low

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Electrotherapy: opioid consumption

Morphine equivalents mg/Kg/48h

Level of evidence: ⊕⊕⊕ Moderate

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Acupuncture: opioid consumption

Time to first PCA (minutes)

• Level of evidence: ⊕⊕⊕ Moderate

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Electrotherapy: pain relief

VAS score mean differences

Level of evidence: ⊕ Very Low

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Acupuncture: pain relief

VAS score mean differences

Level of evidence: ⊕⊕ Low

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Findings

Moderate-certainty evidence

• Electrotherapy and acupuncture reduce/delay opioid

consumption. Low/very low certainty-evidence

• Electrotherapy and acupuncture improve pain.
• Continuous passive motion and preoperative exercise do not

improve pain or reduce opioid consumption. Very low-certainty evidence

• Cryotherapy reduces opioid consumption, but does not

improve pain.

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Conclusions

• Following TKA, there is moderate evidence that

Electrotherapy and Acupuncture are associated with modest but clinically significant reduction and delay in

• pioid consumption.
• However, there was low/very low evidence that Electrotherapy

and Acupuncture improve pain.

• The quality of evidence for other interventions on pain

management was low/very low.

• Given the current opioid crisis, more high-quality studies on

non-drug interventions are needed.

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Policy impact

• Electrotherapy and Acupuncture can be part of evidence-based

guidelines for pain management in patients undergone TKA.

• More funding and initiatives are needed to support non-

pharmaceutical pain management strategies.

• Quality metrics should be developed around the use of non-

pharmaceutical pain management strategies.

• Common interventions such as Continuous Passive Motion

and Cryotherapy for pain management still lack evidence and should be adopted with caution.

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Acknowledgments

Thanks to my amazing mentors and colleagues: Mentor and PI: Tina Hernandez-Boussard, PhD, MPH Mentor: Maria Pia Fantini, MD Colleagues:

• Davide Gori, MD
• Karishma Desai, PhD
• Steven Asch, MD, MPH
• Catherine Curtin, MD
• Ian Carroll, MD
• Kathryn McDonald, PhD

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Questions?

Contact: dariot@stanford.edu